Estradiol and Vulvar and Vaginal Atrophy in Menopause

September 19, 2022 Response by  


Dear Doctor,

I would like to know your thoughts regarding taking estradiol vaginal inserts or cream, prescribed by my doctor for menopausal symptoms of dryness, thinning, etc. Imvexxy estradiol vaginal inserts were prescribed at recent visit, another time estrace .01% was discussed. My doctor assures me they are absorbed locally and do not carry the same concerns as hormone replacement therapy, and is a safe option. I have avoided using in past when recommended by doctor, out of concern of cancer risk, or other undesired consequences. But as need increases, I am considering. What is your advice? The benefits vs risks, of vaginal estrogen, and if needed, the best option for treatment of VVA?

An NFP “Graduate”


Menopausal atrophic vaginitis is a condition that can cause more than discomfort and dryness. There can be an increased risk of vaginal infections from thin, poorly nourished vaginal skin, and also an effect on bladder irritability and infections. So it can be useful to treat it with estrogens. My preference is for bioidentical hormones. The main hormone used, estradiol, can come in the form of inserts like Imvexxy or the generic equivalent or estradiol cream. An additional form is a vaginal ring,the Estring, that lasts three months and emits a small amount of estradiol daily. Women and their husbands usually do not notice the Estring when it is in place or during sexual relations. It is easy to insert. The only drawback to the Estring is the high cost. All of these estradiol vaginal products act locally, and the very small amount absorbed systemically is usually considered insignificant.

Another choice is estriol cream. Estriol is the third of the bioidentical estrogens (E1, E2, E3 - estrone, estradiol, estriol). Pharmaceutical companies do not manufacture it in the USA but it is very common in Europe. It is considered the least carcinogenic of the bioidentical estrogens but is also the weakest. However, it has a special affinity for the vagina and is successfully used for menopausal atrophic vaginitis. The safety record is so good that in some Scandinavian countries, estriol vaginal cream is over the counter. In the USA, estriol vaginal cream can be obtained from compounding pharmacies. Cost can be an issue for all of the vaginal pharmaceutical products with or without insurance, so especially over the age of 65 obtaining products from a compounding pharmacy can be more cost effective. Dr. Mary Davenport